3Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium

Correspondence to Emilie Robert; emilie.robert.3{at}umontreal.ca

Received 29 November 2011

Accepted 21 December 2011

Published 24 January 2012

Abstract

Background Four years prior to the Millenium Development Goals (MDGs) deadline, low- and middle-income countries and international stakeholders
are looking for evidence-based policies to improve access to healthcare for the most vulnerable populations. User fee exemption
policies are one of the potential solutions. However, the evidence is disparate, and systematic reviews have failed to provide
valuable lessons. The authors propose to produce an innovative synthesis of the available evidence on user fee exemption policies
in Africa to feed the policy-making process.

Methods The authors will carry out a realist review to answer the following research question: what are the outcomes of user fee
exemption policies implemented in Africa? why do they produce such outcomes? and what contextual elements come into play?
This type of review aims to understand how contextual elements influence the production of outcomes through the activation
of specific mechanisms, in the form of context–mechanism–outcome configurations. The review will be conducted in five steps:
(1) identifying with key stakeholders the mechanisms underlying user fee exemption policies to develop the analytical framework,
(2) searching for and selecting primary data, (3) assessing the quality of evidence using the Mixed-Method Appraisal Tool,
(4) extracting the data using the analytical framework and (5) synthesising the data in the form of context–mechanism–outcomes
configurations. The output will be a middle-range theory specifying how user fee exemption policies work, for what populations
and under what circumstances.

Ethics and dissemination The two main target audiences are researchers who are looking for examples to implement a realist review, and policy-makers
and international stakeholders looking for lessons learnt on user fee exemption. For the latter, a knowledge-sharing strategy
involving local scientific and policy networks will be implemented. The study has been approved by the ethics committee of
the CHUM Research Centre (CR-CHUM). It received funding from the Canadian Institutes of Health Research. The funders will
not have any role in study design; collection, management, analysis, and interpretation of data; writing of the report and
the decision to submit the report for publication, including who will have ultimate authority over each of these activities.

Footnotes

Funding The project is funded by the Canadian Institutes of Health Research under the financing opportunity ‘Knowledge synthesis’
(NRF 102072).

Competing interests None.

Ethics approval Ethics approval was approved by ethics committee of the CHUM Research Centre (CR-CHUM).

Contributors All authors contributed to conceptualise the study, with leadership from ER and VR. ER wrote the first draft. VR, BM and
PF critically reviewed it and provided comments to improve the manuscript. All authors have read and approved the final manuscript.
VR holds the grant from Canadian Institutes of Health Research.